Daniel E. Bruegger

A retrospective study of tonsillectomy in the under 2-year-old child: indications, perioperative management, and complications.

OBJECTIVE To retrospectively review the experience with tonsillectomy in the under 2-year-old child at an urban childrens hospital. METHODS The medical records of 94 patients under 2 years old undergoing tonsillectomy between May 1, 1995, and May 31, 2000, were reviewed. The methods of tonsil and adenoid excision were noted, as was the use of perioperative steroids, antibiotics, and antiemetics. Outcome measures studied included the duration of postoperative inpatient observation, complications, time to first oral intake, prevalence of postoperative vomiting, type and duration of respiratory support, and improvement relative to operative indications. RESULTS Eighty-two patients (87%) underwent tonsillectomy and adenoidectomy (T&A). Twelve patients (13%) underwent tonsillectomy without adenoidectomy. Patient ages ranged from 12 to 23 months (mean 19.6+/-3.1). Indications included obstructive sleep apnea (OSA) in 51 patients (54%), chronic or recurrent tonsillitis in 30 (32%), both OSA and infection in 11 (12%), and acute tonsillitis with airway obstruction in two (2%). Comorbid conditions were numerous. Preoperative polysomnograms were obtained for eight patients (8%). Hospital stays ranged from 4 h to 16 days. Complications included hemorrhage in four patients (4%) and pneumonia in two (2%). Oxygen was required after discharge from the recovery room in 27 patients (29%), with seven more (7%) requiring either reintubation, continuous positive airway pressure, or nasopharyngeal airways. Of the 88 patients on oral diets, only five (5%) took longer than 24 h to resume oral intake. Two patients (2%) experienced significant emesis after surgery. Four patients (4%) required treatment for dehydration after discharge. CONCLUSIONS Tonsillectomy is a procedure with low morbidity in the otherwise healthy child under 2 years of age. However, we advocate routine postoperative overnight inpatient observation in this age group. We found that young children with comorbid conditions had a higher incidence of complications and required special postoperative management strategies.

Emergence delirium and postoperative pain in children undergoing adenotonsillectomy: a comparison of propofol vs sevoflurane anesthesia.

Background:  Emergence delirium (ED) is a frequent postoperative complication in young children undergoing ENT procedures and it may be exacerbated by sevoflurane anesthesia whereas propofol maintenance has been suggested to decrease the incidence of ED. The aim of this randomized, prospective, double‐blind study was to evaluate the effect of sevoflurane vs propofol anesthesia on the quality of recovery after adenotonsillectomy.

Incidence of and risk factors for airway complications following endotracheal intubation for bronchiolitis

OBJECTIVE: To identify risk factors predisposing to postextubation complications and the incidence of subglottic stenosis following endotracheal intubation for bronchiolitis. STUDY DESIGN AND SETTING: A review of 144 consecutive infants and children intubated for bronchiolitis between 2000 and 2005 at a regional childrens hospital. RESULTS: The mean age at diagnosis was 6.4 months. Follow-up data were available in 93 patients (64.6%), and average length of follow-up was 9.3 months. One hundred and three patients (71.5%) had positive RSV detection. Average duration of intubation was 5.5 days. Twenty-six patients (18.1%) required reintubation during the same admission. Children intubated for less than 3 days and those greater than 12 months of age were more likely to experience postextubation difficulties. Approximately 40% of patients experienced postextubation difficulties. Subglottic pathology was found on endoscopy in 6 patients (4%). There were no cases of long-term subglottic stenosis. CONCLUSION: Immediate postextubation complications are common after bronchiolitis, especially in patients intubated for less than 3 days and greater than 12 months of age. We found no evidence of long-term subglottic stenosis in this population.

Wire grill brush bristle as an unusual foreign body: Report of two pediatric cases

Wire grill brushes are commonly used for cleaning grill grates. Accidental ingestion of a wire bristle from a grill‐cleaning brush is a rarely reported foreign body, with only three prior case reports. Although scarce in the literature, we encountered two pediatric cases at the regional childrens hospital within 1 year. By presenting these two cases, our goal was to raise awareness of this potentially hazardous foreign body. Additionally, we raise a consumer safety issue associated with the use of wire grill‐cleaning brushes as there are currently no ingestion hazard warnings on these products. Laryngoscope,, 2011

Characterization of Cyclooxygenase in Laryngeal Papilloma by Molecular Techniques

Objectives: Demonstrate the induction of cyclooxygenase‐2 (COX‐2) in laryngeal papilloma. Discuss the possible causal role of COX‐2 in papilloma formation. Consider the potential for treatment of papilloma using selective COX‐2 inhibitors. Study Design: Molecular biological analysis of COX‐1 and COX‐2 in laryngeal papilloma. Methods: Tissue samples from five patients with recurrent respiratory papillomatosis (RRP) were analyzed by in situ hybridization, immunohistochemical staining, and reverse transcription polymerase chain reaction (RTPCR) techniques. Results: In situ hybridization to COX‐2 mRNA showed strong autoradiographic signal surrounding fibrovascular cores. COX‐1 autoradiographic signal was low intensity or nondetectable. Normal buccal mucosa biopsies showed low‐density or nondetectable autoradiographic signal for both COX‐1 and COX‐2 mRNAs. In situ hybridization results were corroborated by RT‐PCR studies. Levels of COX‐2 mRNA were 13‐fold more than those in normal mucosa. Immunohistochemical staining for COX‐1 and COX‐2 showed a similar pattern to that seen with in situ hybridization in both normal and papilloma tissues. Conclusions: There is an elevation of COX‐2 expression in papilloma tissues. This may represent a causal role of COX‐2 in the formation and proliferation of laryngeal papilloma. There may also be a role for selective COX‐2 inhibition for the treatment of RRP.

Migrated esophageal foreign body presents as acute onset dysphagia years later: A case report §

Ingested esophageal foreign bodies are commonly seen in the pediatric population. Rarely do they perforate and migrate through neck fascial planes asymptomatically. We present a case of an otherwise healthy 11 year old with sudden onset dysphagia that based on MRI and CT findings was most consistent with an esophageal duplication cyst. However upon surgical exploration, a circular disk like foreign body was identified adjacent to the esophagus. Given the patients age and no reports of purposeful ingestion, it is most likely the patient had ingested this disk foreign body in early childhood, leaving her asymptomatic for 8 years prior to presentation.

Characterization of human papillomavirus in airway papillomas by histologic and biochemical analysis.

The role of human papillomavirus (HPV) in airway papillomas has been well defined in recent literature. The chronicity and recurrence of papillomas has been postulated to be a result of residual viral genome in tissue treated with standard laser techniques. Thirteen patients with airway papillomas were selected for study with polymerase chain reaction (PCR) methods to detect viral DNA. Specimens taken prior to laser therapy and specimens taken at laser margins were consistently positive for HPV DNA by PCR. The HPV DNA is apparently present in tissues after macroscopic disease has been ablated by laser techniques. Histologic analysis of laser biopsies demonstrated fragments of squamous epithelium with cytologic features of HPV infection. Laser treatment is ineffective in eradicating HPV-infected tissues from airway papillomas, and this finding supports the notion that recurrence is a product of HPV incorporated into tissue not ablated by laser irradiation. Specific methods, results, and clinical correlation will be discussed.

Differential Gene Expression and Pathway Analysis in Juvenile Nasopharyngeal Angiofibroma Using RNA Sequencing

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascularized and locally aggressive tumor that typically presents in adolescent males. The molecular biology of this tumor remains understudied. We sought to identify differentially expressed genes in the JNA transcriptome through messenger RNA sequencing of primary fibroblasts from 2 tumor explants and tonsil tissue from tumor-free subjects. In total, 1088 significant, differentially expressed genes were identified with 749 upregulated and 339 downregulated. Pathway analysis identified a number of activated signaling pathways, most notably, the vascular endothelial growth factor (VEGF) pathway (adjusted overlap P = .03). VEGF-A showed a 4.4-fold upregulation in JNA samples. In addition, the angiogenic receptor, fibroblast growth factor receptor 2 (FGFR2), was not present in tumor-free samples but increased in JNA. We validate these findings with immunohistochemistry, demonstrating upregulation of VEGF and FGFR2 in patient sections. Inhibition of the VEGF or FGFR signaling axes may have therapeutic potential in the treatment of JNA.